BILL NUMBER: SB 1746	CHAPTERED  09/29/00

	CHAPTER   849
	FILED WITH SECRETARY OF STATE   SEPTEMBER 29, 2000
	APPROVED BY GOVERNOR   SEPTEMBER 28, 2000
	PASSED THE SENATE   AUGUST 30, 2000
	PASSED THE ASSEMBLY   AUGUST 28, 2000
	AMENDED IN ASSEMBLY   AUGUST 24, 2000
	AMENDED IN ASSEMBLY   JULY 6, 2000
	AMENDED IN SENATE   APRIL 10, 2000

INTRODUCED BY   Senator Figueroa
   (Coauthor:  Senator Solis)
   (Coauthors:  Assembly Members Havice, Honda, Kuehl, Machado, and
Washington)

                        FEBRUARY 23, 2000

   An act to amend Section 1373.65 of the Health and Safety Code,
relating to health care service plans.


	LEGISLATIVE COUNSEL'S DIGEST


   SB 1746, Figueroa.  Health care service plans:  termination of
provider:  notification:  enrollee.
   Existing law provides for the regulation and licensing of health
care service plans by the Department of Managed Care.  A willful
violation of the provisions governing health care service plans is a
crime.
   Existing law requires a health care service plan 30 days prior to
termination of a contract with a medical group or individual practice
association to provide affected enrollees with a written notice of
the change.  Existing law permits the plan when terminating a
contractual arrangement with an individual provider within a medical
group or individual practice association to have that group or
association notify the enrollees who are patients of that provider.
   This bill would specify the method for delivering written notice,
and the procedure to follow if the written notice is returned as
undeliverable.  The bill would require the notice to provide
instructions for enrollees to choose a new "primary care provider"
and would define that term.  The bill would permit an enrollee to
self-refer under specified conditions.  The bill would exempt from
these requirements a health care service plan contract that provides
benefits through preferred provider contractual arrangements, if the
plan does not require the enrollee to choose a primary care provider.

   Because a violation of this bill's requirements with respect to a
health care service plan would be a crime, this bill would impose a
state-mandated local program by creating a new crime.
  The California Constitution requires the state to reimburse local
agencies and school districts for certain costs mandated by the
state.  Statutory provisions establish procedures for making that
reimbursement.
   This bill would provide that no reimbursement is required by this
act for a specified reason.


THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:


  SECTION 1.  Section 1373.65 of the Health and Safety Code is
amended to read:
   1373.65.  (a) (1) Thirty days prior to a plan terminating, for any
reason, a contract with a medical group, individual practice
association, or primary care provider, the plan shall provide written
notice of the termination to enrollees who are at that time
receiving a course of treatment from a provider of that medical
group, individual practice association, or primary care provider, or
are designated as having selected that medical group, individual
practice association, or primary care provider for their care.  The
notice shall include instructions on selecting a new primary care
provider.
   (2) If a plan without advance notice to a primary care provider
terminates the primary care provider because of his or her
endangering the health and safety of patients, committing criminal or
fraudulent acts, or engaging in grossly unprofessional conduct, the
notice requirement of paragraph (1) is not applicable.  Instead, the
plan within 30 days of having terminated the primary care provider
shall provide written notice of the termination to the enrollees who
have selected that primary care provider.
   (b) When a plan terminates a contractual arrangement with an
individual provider within a medical group or individual practice
association, the plan may request that the medical group or
individual practice association notify the enrollees who are patients
of that provider of the termination.
   (c) A plan shall disclose the reasons for the termination of a
contract with a provider to the provider only when the termination
occurs during the contract year.
   (d) Notwithstanding subdivision  (c), whenever a plan indicates
that a provider's contract is being terminated for quality of care
reasons, it shall state specifically what those reasons are.
   (e) A plan that relies on primary care providers shall have a
process in place to assure that patients who do not have a primary
care provider have access to medical care, including specialists.
   (f) If an enrollee has not been notified pursuant to subdivision
(a) that his or her primary care provider has ceased to be affiliated
with the enrollee's plan, the enrollee is not required to have the
approval of a primary care provider to authorize a referral within
the plan. All self-referrals within the plan shall be approved for a
period of 60 days from the date of the termination of the enrollee's
primary care provider or until a primary care provider is assigned or
chosen, whichever is earlier.
   This subdivision does not apply if the enrollee's plan utilizes a
process for automatically assigning enrollees a primary care
provider, or if the enrollee otherwise has direct access to a primary
care provider.
   A plan may not retroactively assign an enrollee to a new primary
care provider to avoid financial responsibility for any enrollee
self-referrals due to a failure to notify the enrollee pursuant to
subdivision (a).
   (g) All notifications required by this section shall be by United
States mail.  If the notice to the enrollee is returned as
undeliverable, the plan shall make a good faith effort to notify the
enrollee at the first appropriate contact with the plan.
   (h) (1) For purposes of this section, "primary care provider"
means a primary care physician, as defined in Section 14254 of the
Welfare and Institutions Code, who provides care for the majority of
an enrollee's health care problems, including, but not limited to,
preventive services, acute and chronic conditions, and psychosocial
issues.
   (2) For purposes of this section, if a specialist meets the
criteria of paragraph (1), he or she may be a primary care provider
for an enrollee.
   (i) This section is not applicable to a health care service plan
contract that provides benefits to enrollees through preferred
provider contracting arrangements if the plan does not require the
enrollee to choose a primary care provider.
  SEC. 2.  No reimbursement is required by this act pursuant to
Section 6 of Article XIIIB of the California Constitution because the
only costs that may be incurred by a local agency or school district
will be incurred because this act creates a new crime or infraction,
eliminates a crime or infraction, or changes the penalty for a crime
or infraction, within the meaning of Section 17556 of the Government
Code, or changes the definition of a crime within the meaning of
Section 6 of Article XIIIB of the California Constitution.
